Examination of Witnesses (Questions 1-19)
Mr Jurgen Scheftlein
6 JULY 2006
Q1Chairman: Welcome to our session. We are very
glad that you could come and assist us with our inquiry at rather
short notice—I am sorry about that. I would also like to
express my thanks to your Directorate for letting you come over
and speak with us. To start with housekeeping points, the session
is open to the public. Although I do not think there are any members
of the public here, it is a public session, and it will be recorded
for possible broadcasting or webcasting. A verbatim transcript
will be taken and it will be sent to you so that if you feel you
have been misrepresented, or you feel you need to change something,
you can do that and then it will be attached to our evidence should
we do a report and publish the report. If you feel, during the
course of our hour, that you have not been able to fully explain
something we are very happy to receive supplementary evidence
from you by e-mail or letter. That would be most welcome. You
should have had or seen a register of Members' interests. Going
on to the substance of the matter, this is a paper which has caused
us, it is fair to say, a certain amount of concern. The inquiry
is only just starting and we are still trying to get to grips
with the subject. It will continue when Parliament resumes in
October, and we may want to invite more evidence from the Commission
at that stage. What we wanted to achieve today was to get a briefing
from you as the official closely connected with the drafting of
the Green Paper and so on, so that you can set the scene for us
and we can understand what the Commission's objectives are in
publishing this paper. Obviously, it is a consultative document
and we have seen some of the responses which have gone to you.
You may not, therefore, be able to give definitive answers as
to what is going to happen next, but the scope of something called
mental health policy is extremely wide. We have several people
in the room who know quite a lot about it. It also includes some
very sensitive issues and it raises issues of competence and subsidiarity
as well. We hope that you will be able to give us a clearer idea
of what the mental health strategy is likely to involve in practice,
what the priorities are and what the roles of the Member States
and the Commission are going to be. I hope you understand where
we are coming from. It is not so much that we are critical, it
is more that we want to know what the main thrust of the Commission's
ideas and of this consultation paper really are. Could you start
by stating your name for the recording, and if you want to make
an opening statement we would be very happy to hear that. Otherwise
we will move straight into questions. Have you been able to understand
and hear what I have been saying?
Mr Scheftlein: Yes, I understood you very well,
and we can begin. My name is Jurgen Scheftlein, I am working with
the European Commission Directorate General for Health and Consumer
Protection in a unit which is dealing with health determinants.
I am the administrator in charge of the Green Paper Improving
the Mental Health of the Population, Towards a strategy
on mental health for the European Union which the Commission
adopted on 14 October last year. The idea behind publishing this
paper was, in principle, that we saw, through work that we have
been undertaking through projects under the public health programme,
that the burden of mental illness is increasing and that this
is creating challenges for Member States and, also, for the attainment
of the strategic policy objectives of the European Union. We wanted,
in the aftermath of the WHO Ministerial Conference in Copenhagen
in January 2005, to make a contribution to identifying the challenges
and then addressing it commonly, and to do this together on the
basis of this document. The document objective was first to raise
the visibility of mental health as an area of concern for public
health and, also, for other public policies, and then to launch
a debate about whether the European Union should get involved
and should develop a strategic approach on this or not. Since
the launch of this document in October 2005 we have organised
a high-level launch conference in Luxembourg with ministers and
members of parliament and others involved, and then we had three
meetings at technical level from January to May. Since 31 May
the consultation has been closed officially but, of course, we
still receive comment and reactions. For instance, the European
Parliament will only adopt its report on the Green Paper in October.
I am very pleased and honoured by this invitation to discuss this
document with you, and look forward to the discussion that we
will have.
Q2 Chairman: Thank you for that background
introduction; it was rather useful to get the timing and programming
of the whole thing clear. If I can start off, can you explain
a little bit more about the way in which the Green Paper relates
to the WHO Mental Health Action Plan for Europe, and can you also
outline the main features of the WHO Plan and the role which it
apparently envisages for the Commission?
Mr Scheftlein: Yes. It is no coincidence that
the Green Paper was published a few months after the WHO Ministerial
Conference on Mental Health in Helsinki. Mr Markos Kyprianou,
the European Commissioner for Health and Consumer Protection,
participated in this conference, together with the representatives
of Member States, and the Commission service also worked together
with the WHO in preparing this conference. The new feature of
the WHO declaration and action plan was that it brought mental
health up to the highest level of policy-making, on the one hand,
and it created a commitment which has not been existing beforehand
and, at the same time, it developed a very comprehensive strategic
approach, ranging from promotion and prevention through care and
treatment to rehabilitation. So it covered a very wide range of
areas and one area which was certainly new, as an work area for
the WHO was the one of promotion and prevention, which is the
starting point of the Commission's work on mental health. The
Commission has been a co-organiser, even a collaborative partner
in this conference. It was only reasonable then, after the conference,
to be involved in the follow-up to the conference because the
conference is only a starting point of work, and what happens
afterwards is much more important. There is a sentence in the
conference declaration inviting the Commission to support the
implementation of the declaration action plan—within its
scope of competences, of course. So that is how things are related.
The Commission will have to focus on those fields in the WHO action
plan—the 12 fields ranging on the points I mentioned—in
which we are working, and where we have the competences to act,
and that is mainly promotion and prevention, supporting vulnerable
groups, information and research, and addressing discrimination
and stigma. The complicated thing about mental health is that
it covers so many different policy areas. It concerns practically
the whole range of community policies: Ourselves in the Directorate-General
for Health and Consumer Protection address issues like promotion
and prevention. Stigma and discrimination is the work area of
the colleagues in the Directorate-General for Employment, Social
Affairs and Equal Opportunities. Then the Commission also finances
research under the framework programme on research. Our colleagues
from Eurostat but, also, ourselves (under the public health programme)
collect information and data about the status of mental health
of the population. In summary our Green Paper initiative, is a
response to the WHO Action Plan. It is an offer to the WHO and
to the other actors whom we want to involve, including Member
States, to work together with us in developing and implementing
a strategy at EU-level. We published it as a Green Paper because
we believe if the Commission would have come out with a proposal
for a strategy it would have been a kind of artificial product.
Through this discussion we hope to develop a consensus on the
direction of our work and on the objectives together with the
WHO but mainly, also, with Member States to have a mandate for
action in the future.
Chairman: Thank you for that. I think
we have gone a step further along the way.
Q3 Lord Trefgarne: While the aspirations
of the Commission in this matter are, of course, entirely good,
is there not a risk of confusion between the activities of the
WHO, the activities of Member States and, now, the activities
of the Commission as well?
Mr Scheftlein: I would not see it like that.
On the other hand, I agree that the working areas and the balance
of work has shifted after the WHO Ministerial Conference. For
instance, you can see it from the fact that before the conference
we had a clear division of work. Member States had their own work;
organised their mental health systems and delivered mental health
services in their own right, of course, and the Commission would,
on the basis of the provisions in the Treaty, support this in
the fields of promotion and prevention and collection of information.
The role of the WHO had been to focus on treatment aspects and
to advise Member States on this. After the conference the WHO
said where promotion and prevention is part of our action plan
so we also have to work on this ourselves.
Q4 Lord Trefgarne: Is the EU a member
of the WHO in its own right?
Mr Scheftlein: No, no. The EU is not a member
of WHO.
Q5 Lord Trefgarne: It is the Member States.
Mr Scheftlein: Yes, but we had a common understanding
of the roles of the Council of Europe, the WHO and the Commission
versus Member States. This has shifted a bit towards more co-operation
across the working fields of these organisations.
Q6 Lord Trefgarne: A common understanding
between the WHO, the Commission and the Member States?
Mr Scheftlein: Yes, we are mainly promoting
a common understanding between the three organisations. We have
regular meetings between these three organisations, in which we
co-ordinate our line of work.
Q7 Chairman: That is the WHO, the Community
and the Council of Europe?
Mr Scheftlein: And the WHO, yes.
Q8 Chairman: Those three?
Mr Scheftlein: Yes, plus, of course, the Commission
is participating in regional committee meetings where Member States
are meeting with the WHO. So we had a rather clear division of
work, but now we are moving more towards working together in partnership,
and that means that WHO helps us in the Commission in working
on promotion and prevention, for instance.
Q9 Earl of Dundee: You mentioned the
three bodies, the Council of Europe, WHO and the Commission, and
the allocation of tasks and the division of work. Could you say,
just very generally, what kind of focus would be given by the
Council of Europe, by the WHO and by the Commission?
Mr Scheftlein: Yes. Very generally, the task
of the WHO would be to advise Member States on issues of health
services and treatment—aspects whereas the role of the Council
of Europe would be to work on human rights aspects, and the Commission's
role would be in the rather innovative field of mental health
promotion and prevention, plus collection of health information
and health status data. The latter is also a field of work of
the WHO. One could say that WHO has with its Mental Health
Atlas established an inventory of resources invested in mental
health and of service organisation, whereas the Commission then
would focus on aspects of the health status in the population,
on determinants, and on preventive and promotion policies, so
to say.
Q10 Lord Trefgarne: Very great care is
going to be needed to avoid confusion between these different
roles.
Mr Scheftlein: Yes, but the most important necessity
is certainly to have a common philosophy and to work together.
I can say that I have a very good and close co-operation with
colleagues at WHO Europe, the regional adviser Matt Muijen and
his collaborator Dr Jane-Llopis, and so we feel that there is
a scope of mutual strengthening by working together. The WHO can
contribute its expertise into our work. Also, since recently we
have a strand reserved for co-operation with international organisations
under the public health programme. So a certain share of the money
under the public health programme is reserved for WHO, and there,
for instance, now the WHO is doing a project, a benchmarking exercise,
to identify the state of play in Member States versus the WHO
Action Plan. Furthermore, as the European Commission, we can offer
more regular meetings with all the Member States together. So
WHO advises Member States bilaterally whereas we have the possibility
to bring together all Member States plus WHO which means that
the work from WHO can be disseminated in a more efficient way,
not only bilaterally.
Q11 Baroness Gale: I have got two questions
to put to you, as they are linked, on definitions. The first one
is: does the Commission foresee practical difficulties in the
very broad definitions of mental health and mental ill-health,
which are used by the WHO? Secondly, we have received written
evidence suggesting that "emotional well-being" would
be a useful definition. Does the Commission have views on that
definition?
Mr Scheftlein: Yes. Concepts and definitions
are certainly an important aspect in this work and when you have
them then you need also to clarify what you want to cover and
what you want to segregate from the work. Now, for mental health
and mental ill-health as definitions, we thought, in the sense
of partnership that I have just described but, also, in a sense
of referring to consensual terms, that it was the most logical
step to use the WHO's definition on mental health and mental ill-health.
In fact, we had much discussion about what term we could use:
mental illness, mental ill-health, mental disorder—there
are so many and there is always one group which is suggesting
it is a politically incorrect one. Then we decided to refer to
mental ill-health. These are very broad definitions, I know, but,
on the other hand, they fit to the approach of the paper, I would
say, because what we propose in our Green Paper is a public health
approach to mental health and we do not limit it and present it
as a medical issue alone. It is very much a medical issue, but
not only, and for us we want to look first into health and only
then into disorders. We do not want to adopt a medical approach
and focus on severe disorders or clinically-defined disorders
as they are classified in ICD 10, an international system classifying
mental disorders. Therefore for the purpose of early prevention
and of the promotion of wide definition issues, like stress in
the workplace—"strain" I think is the true English
word—
Q12 Chairman: Stress.
Mr Scheftlein: Yes, caused by strain. That may
not be a clinical disorder but it may lead to one if no intervention
takes place. So this attempts to use agreed definitions, and then
the wide scope of our work were the reasons to use these definitions.
"Well-being" as such is certainly a good term because
we think what we address is very much about quality of life and
well-being. "Emotional well-being", yes, is interesting
as a term. Possibly it might exclude disorders with an organic
background. While we do not focus on them, is it possible to fully
exclude them from the work? Sometimes there is also a lot of interaction
between social aspects and biological aspects. Therefore, it could
be a term that we could use to describe what we are talking about,
for instance, in the school environment, where it could be a very
valuable concept in addressing children and adolescents.
Lord Colwyn: I think I would like to
see the word "distress" as a definition.
Chairman: Mental distress.
Q13 Lord Colwyn: Mental distress. This
is such a vast subject we are getting into. You talk about it
affecting every fourth citizen; 27 per cent of adult Europeans
are estimated to experience some form of mental ill-health. It
is such a massive subject. This is my concern with this inquiry;
I just do not know how we are going to be able to cope with it.
Mr Scheftlein: There are different figures.
There are figures suggesting that at any point in time a quarter
of the population are affected, and there are other WHO statements
that at one moment during life every fourth citizen is affected
by it. I do not think that every mental health problem needs medical
intervention; our objective is mainly to raise awareness of how
important this is for life and that promotion and prevention are
possible, and that once a person has a problem that it should
seek help, and that its surroundings should show understanding
and avoid for instance, stigma. People with mental health problems
try to hide that very often, and employers have no understanding
or their environment has no understanding. But showing that mental
health problems are a common part of reality helps people who
have problems to feel normal citizens and to accept that they
should seek help and can get help. So we have a very successful
project called European Alliance against Depression under the
public health programme. It is not a big one but it is one that
finds a lot of interest. It is about informing media, teachers,
priests, police and doctors about depression as a sickness, as
an illness, which is often not detected, so that people have to
see whether there are signs of that. That has led, in a pilot
case of a German research project in a region, to a decrease of
suicidal acts by around 25 per cent. The project leader told me
that one of the most important aspects is that people, when they
see campaigns, feel understanding and that helps them to go to
a doctor and tell them about their mental health problems.
Q14 Earl of Dundee: Has that scheme graduated
beyond the pilot stage?
Mr Scheftlein: It was developed as a German
research project, and then it was taken up at EU level under the
public health programme. It was implemented in 15 Member States
during the one-and-a-half years, and now it has been extended
to all Member States, but not fully covered—it is only implemented
in those regions which are interested. It is very much a demand-led
project. So you need to find personalities who are interested
in this and who are ready to invest some of their time into it,
and then they get standardised material and there are meetings
to exchange, so there is a framework that helps them to develop
their activities.
Q15 Baroness Howarth of Breckland: This
really gets to the heart of whether or not we should pursue our
inquiry. The issue has been very well demonstrated by the little
debate that has just gone before. The Bamford report, as you will
know, says that positive mental health cannot be gained by treating
mental disorders alone. That is what we have been discussing.
However, it does lead us into saying what is it that we can do—indeed,
what is it that the Commission can do—that adds value to
what the Member States can do for themselves. Therefore, where
should we be placing our energies, because we cannot possibly
look at the whole of the mental health/mental illness scenario?
If we are going to do something useful what would you see that
as being?
Mr Scheftlein: Firstly, of course, we do not
want to intervene into Member States' actions. However, we understood
from the WHO Ministerial Conference that mental health has become
a field of interest, a priority, in many Member States. We know
that situations in Member States are different and they will never
be equal because they reflect cultures and traditions and many
factors, but we think that there might be an interest in Member
States in exchanging and seeing whether they can work together
and identify common recommendations on some fields of high priority.
In fact, in the past we have worked together only with researchers
when we implemented our public health programme. We felt that
it is not sufficient to develop research and then not to communicate
it to the actors in Member States. That is another reason why
we did develop the Green Paper.
Baroness Howarth of Breckland: If there
were two questions you wanted this Committee to address—
Lord Trefgarne: Or even one!
Q16 Baroness Howarth of Breckland: —that
would enable you to further your work in the Green Paper, what
do you think they would be?
Mr Scheftlein: My interest would be what you
would define as those priorities where you would wish to share
knowledge with other Member States.
Q17 Baroness Howarth of Breckland: It
is about information and dissemination that you would really like
the focus?
Mr Scheftlein: No, I would like to go further.
I think it would be the involvement of many other society actors,
like the business environment, like the school environment—so
the public health approach. How can we demonstrate the value of
positive mental health to other policy areas, and how can we convince
them to invest in better mental health and to integrate it into
their actions?
Q18 Baroness Howarth of Breckland: So
it is in situations of employment, education, general community
situations and how one conveys information to those communities
about positive mental health programmes?
Mr Scheftlein: Yes, information, but also then
consensus building with them. Not only sending recommendations
to them but involving them in work. May I add one point? I also
think it is crucial, then, not only to do this from the point
of view of public health policy but, also, to consider the objectives
of the other elements. So, for business, it is productivity; for
instance, to show that mental health has an impact on productivity,
and that promoting mental health and boosting productivity is
possible, and that promoting life skills in children is possible
for success in later life.
Q19 Baroness Greengross: Following on
very well from that, I think we are in danger, and you are in
danger, if I may say so, of giving very positive, nice messages,
but we hear those all the time. It seems to me that it is the
economic arguments that are really going to change people's behaviour.
One of the most strong of those might be that if you invest in
combating mental ill-health (or mental distress, as my colleague
called it) in the workplace, for example, what the results would
be and, therefore, the economic consequences of mental ill-health
and the investment needed to combat it in hard data would seem
to me to be something you could do which would be extremely helpful.
I understood earlier that David McDaid, who I worked with quite
a lot, is doing some work with you as an economist here at the
LSE. That interests me because I think that is where you could
make such a difference, with hard data to business, to employers,
to educationalists or whoever. Is there a possibility that you
could look at not just the economic consequences but the economic
investment and what the return on that investment might be, in
hard terms?
Mr Scheftlein: Yes. We have projects looking
into the economics of mental health, led by the London School
of Economics, and these projects could be used to develop this
evidence. At the moment the evidence is very striking about the
increase of the problem. There is less knowledge about the success
of promotion aspects in companies and preventative action. But
that is something we would have to deliver, that is true. Recently,
two weeks ago, colleagues of mine participated in a business meeting
called "CSR (Corporate Social Responsibility) marketplace"
where companies exchanged best practice, including towards their
employees. We think that this work on corporate social responsibility
could also be an avenue for disseminating information and, also,
for involving companies in mental health promotion. So we have
networks of healthy enterprises, and the best thing would be if,
once there was the scientific data, like through the projects
from David McDaid, businesses themselves would be present and
say: "We have done this and we have learned it works. It
is possible." That is something that we will try to do through
the mental health strategy and in commonality with the colleagues
working on health and safety at work and in Commission service
for Employment policy.
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